The Doctor Is In

Ever experience a burning feeling and discomfort in the chest? Heartburn may likely be the culprit.

An occasional occurrence may not be cause for alarm. But if it starts happening frequently, the cause may be acid reflux disease or GERD, the more advanced gastroesophageal reflux disease.

Heartburn occurs when stomach acid rises up the esophagus due to the weakening of the lower esophageal sphincter, a ring of muscle located at the entrance to the stomach. Due to a variety of factors, this muscle can malfunction or not entirely close.

It's not uncommon; many people experience the unpleasant effects of acid reflux at some time of life. The most common symptoms include a caustic sensation in the chest and sour or bitter taste. Other uncomfortable signs may include bloating, a feeling that food is stuck in the throat, nausea, unexplained weight loss, bad breath, dental erosion, throat problems and more.

Heartburn should not be ignored nor should antacids should be constantly used. A consultation with a primary care physician or, if recommended, a gastroenterologist, can provide the suggestions to get this problem under control. A series of diagnostic tests can reveal the primary cause.

The first step to relief may be lifestyle changes. Positive results may be realized by:

Losing weight

Eating earlier in the evening

Sleeping with the head or torso more elevated

Stopping smoking

Reducing salt intake and eating more fiber

Exercising more

Changing medications.

If these changes do not bring relief, medications and therapies may be prescribed.

Acid reflux disease should not be ignored. If untreated, serious complications can result, including damage to the lining of the esophagus, internal bleeding, ulcers or even breathing problems. It can even lead to Barrett's esophagus, a change in the lining of the esophagus, which can be a precursor to a potentially fatal cancer.

Heartburn is uncomfortable, but it can be managed. Seeking a diagnosis, taking precautions, making lifestyle changes and, if necessary, receiving more advanced treatment can make it possible to resume a pain-free life.

This article was written by Dr. Madhavi Bhoomagoud, a gastroenterologist affiliated with MidState Medical Center.

It is hard to imagine how many facial tissues are used each year in the United States by people who are suffering from the effects of an estimated 1 billion colds. Children can average six to 10 colds while adults average two to four colds annually.

The cause is attributed to more than 200 varieties of viruses, according to the National Institute of Allergy and Infectious Diseases. For most people, the sneezing, sniffling and scratchy throat is gone within a week or two.

Not everyone is so lucky. Sometimes the cold symptoms continue or intensify and evolve into sinusitis. A person's sinuses may become inflamed due to an infection or other problem. The Centers for Disease Control and Prevention reported that in 2011, almost 30 million adults experienced at least one bout of sinusitis.

Sinuses are facial cavities that are normally filled with air. However, if they become blocked, mucus will not drain and infection can occur, leading to sinusitis. Sinus infections can be due to viruses, bacteria, and fungi.

There are four types: acute, which can last up to four weeks; subacute, which can continue as long as eight weeks; chronic, which can last longer than eight weeks; and recurrent, which is classified as several episodes each year.

Sinusitis is an uncomfortable or even painful condition. A person may experience facial pain and pressure, stuffiness and congestion, post-nasal drip and/or a cough. Some people also develop fever, fatigue, bad breath, and dental pain.

The problem may be caused by swelling of nasal mucous membranes and blocked drainage ducts due to colds or uncontrolled allergies. Nasal abnormalities such as polyps, deviated nasal septum or a compromised immune system can also contribute to the problem.

It could be time to call a doctor if the symptoms continue for as long as two weeks or worsen.

To diagnose, physicians will review the symptoms and perform a physical exam. He or she may look in the nose for pus, polyps, or deviated nasal septum. He or she may shine a light against the sinuses and tap over a sinus area to detect infection. In some cases, imaging tests may be used to view the bones and tissues. Ear, nose and throat specialists may use a fiberoptic scope inside the nose to view the sinuses. Allergy tests, blood tests to discern immune deficiencies, and nasal cultures may also be conducted.

What can a person do? There are several self-care measures that can help. A warm, moist washcloth applied to the face several times daily can help as can inhaling steam in a hot shower. Using nasal saline or sinus rinse can also help to flush pus and allergens out of your nose and sinuses.

Unfortunately, recovering from sinusitis takes time while the infection goes away. Antibiotics may be prescribed if the sinus infection is bacterial. People diagnosed with chronic or recurrent sinusitis may require surgery if medications are not effective or if a deviated septum or polyps are the cause.

Thankfully, sinusitis is one condition that can be prevented by avoiding colds and flu, treating allergies, taking preventative measures, and treating problems promptly.

With the proper precautions, you may soon be breathing easy.

This article was written by Dr. Edward Lee, a board certified ear, nose and throat physician who practices with Hartford HealthCare Medical Group and is affiliated with MidState Medical Center.

A recent study from the American Journal of Sports Medicine suggests that teens are four times more likely to suffer a concussion today than a decade ago. In essence, concussions are mild traumatic brain injuries induced by an impulsive force that results from an indirect or direct impact to the head, face, neck or somewhere on the body. More than 80 to 90 percent of concussion patients present with a rapid onset of symptoms that resolve within five to seven days. However, for a percentage of patients, further follow-up care may be necessary.

Parents of athletes should be on the lookout for symptoms of a concussion, especially because symptoms can sometimes be delayed. The warning signs are divided into four major categories: physical, cognitive, sleep and emotional. Physical symptoms can include headache, nausea, dizziness, visual or balance problems, fatigue or sensitivity to light and noise. Cognitive issues include difficulty concentrating or remembering and a sense of feeling foggy or slowed down. Sleeping too little or too much can also be a symptom, as can emotional irritability, sadness or nervousness.

There are immediate and long-term consequences for those who suffer a concussion. Immediate symptoms can develop into permanent brain injuries, memory loss, headaches, inability to concentrate, dizziness, irritability, fatigue, and even sensitivity to sound.

When a player suffers a major blow, it's important that they are checked out immediately. There is a testing protocol that should be administered called ImPACT, which is a 20 minute neuro-cognitive test. This test, which can only be administered by healthcare providers with specialized training, includes a thorough evaluation of multiple cognitive functions, such as attention span, memory, reaction time, non-verbal problem solving and response variability.

Connecticut is one of a few states that has recently passed a student athlete concussion law, which regulates how trainers handle players who might have a concussion. The law essentially says "when in doubt sit it out," requiring trainers to remove players in question from a game and not send them back in.

The primary goal in managing concussed athletes is always getting them normalized and back to activities and school. With appropriate follow-up care, these athletes will be back into the swing of things in due time.

This article was written by Dr. Subramani Seetharama, a physiatrist and medical director of Hartford HealthCare Rehabilitation Network, who oversees MidState Medical Center's Concussion Clinic located at 680 S. Main Street, Cheshire.

At some time of life, almost every person experiences back pain, often in the lower region of the back. Sometimes the pain is short-lived while for other people it is chronic or acute.

Unfortunately, as people age they are more susceptible to back problems primarily due to the natural degeneration of the disks. Over time, disks lose their water and elasticity becoming stiffer and harder, which affects the movement of the spine. Arthritis can also be a cause, affecting the back as it may in other joints.

However, people of all ages can develop back pain. Sometimes little can be done to prevent back problems if the causes are hereditary, due to an infection or kidney stones, a condition such as scoliosis or certain diseases. Muscle or ligament strains, disk problems and combination of several factors may cause the pain.

Lifestyle may also contribute to back problems. Being overweight or in poor physical condition, performing work requiring lifting and twisting or extended sitting can all influence back strength and health. Regular exercise, maintaining a healthy weight, standing straight and learning how to lift can all help to keep the back strong.

Many people can deal with the pain if it is infrequent. Some back pain is only temporary as in the case of pregnancy when additional weight causes strain. However, physicians recommend that if symptoms include neurological problems such as pain radiating down the leg, numbness, tingling and difficulty moving one foot, further investigation is warranted.

Just because back pain is more serious or chronic, it does not mean that surgery is necessary. Non-surgical treatment including exercise, physical therapy, heat, massage, over-the-counter medication, yoga or Pilates or a combination of these can have good results in restoring the back.

If such treatments are ineffective, surgery may be recommended. Fortunately, new technologies have resulted in less invasive surgery and ultimately quicker recovery times. These advances also enable surgeons to be able to treat broader conditions that they weren't able to previously.

Better imagery has played an important role in these surgical advances. For example, a 3-D C Arm that curves around a patient provides a 3-D, rather than flat, image to surgeons while they are in the operating room, giving them a more thorough understanding of the problem. Navigation systems, similar to a GPS, use probes to map a patient's body, which enables medical professionals the ability to zero in on a precise area. An endoscopic camera provides a microscopic view of the exact spot through a small puncture hole rather than a large incision.

Coupled with advanced imagery technologies and specialized devices, it is possible to complete sophisticated back surgeries in less time. As a result, patients are able to quickly return to their active lives.

Total hip replacement surgery has improved the lives of hundreds of thousands of people over the past several decades. While hip replacement surgery restores mobility and quality of life in many patients, it is still considered major surgery and requires adequate rehabilitation therapy and recovery time before the patient can return to normal activities. Fortunately, for today's hip replacement patients, a newer approach to surgery may speed healing and get you back on your feet sooner. The approach is called the anterior approach.

In most cases, a hip replacement procedure is performed using a posterior approach; that is, accessing the hip joint from the patient's back. However, when you operate from the back of the patient, your surgeon must cut and detach muscles from the pelvis and femur in order to access the hip joint. When you detach them, it destabilizes the hip, increasing the risk of dislocation after surgery. Because of the risk factors for dislocation, patients must avoid certain positions like bending and crossing the legs.

Today, research suggests that an anterior approach-accessing the hip joint from the front of the patient's body-gives patients even better results. First developed more than 50 years ago, the anterior approach is rapidly gaining favor because it is much less invasive than the posterior approach.

From the front, a natural opening between muscles allows the surgeon to access the joint while leaving the muscles intact, so the risk of dislocation is far less. This also means that patients don't have to avoid certain positions for weeks after surgery like with the posterior approach.

Additionally, since muscles aren't cut, the anterior approach causes less trauma to the body. As a result, patients experience less pain, a shorter length of stay in the hospital, faster recovery and faster return to normal activity levels.

There are other advantages, too. Because the patient lies on his or her back for the anterior operation, surgeons can readily use X-ray during surgery to verify correct leg length and proper placement of the components. This helps ensure better results for the patient and a longer life for the prosthesis. The patient's position also makes it easier to replace both hips at once, since the patient doesn't have to be turned.

Considering that the average age of a hip replacement patient is 65, and that advances in medicine allow people to continue to live longer, more active lives, it is all the more important to identify less invasive and traumatic approaches to this common surgery.

This article was written by orthopedic surgeon Obi Osuji, MD. Dr.Osuji is affiliated with MidState Medical Center and practices with Hartford HealthCare Medical Group Orthopedic Specialists.

An estimated 40% of Americans suffer from the daily effects of heartburn, and approximately 20% have been diagnosed with GERD, or gastroesophageal reflux disease. What some people don't realize, however, is that there are highly effective and safe surgical options to help relieve them of this uncomfortable, painful and oftentimes disruptive disease.

What is GERD? GERD occurs when the reflux of stomach contents causes troublesome symptoms and/or complications, which can affect a person's health, comfort, and well-being. To know how to treat GERD, your doctor first needs to understand what may be causing it. In an effort to make a proper diagnosis, your doctor may first try prescription antacid medications, such as Nexium, Protonix, or Prilosec.

When the symptoms are not well-controlled with any of these, it's often reason to do further testing to see what may be causing the pain and discomfort. Testing may include endoscopy, barium esophagram, manometry or pH studies. In some cases, a structural cause may be found, which may require a procedure to address. These may be from an injury, a narrowing of the esophagus, a hernia, or in more rare cases, from cancer. Knowing which of these problems the patient has can help steer the course of treatment.

For patients who show no anatomical abnormalities, and have only mild reflux symptoms, it is often recommended that they try lifestyle modifications. These may include changing their diet to avoid foods which are known to cause reflux, weight loss, along with antacid medication. For those individuals with more severe disease, longer term antacid medication has traditionally been the standard approach.

However, research has shown that long-term use of some antacid medications, such as PPIs (proton pump inhibitors) can potentially be associated with unintended side effects, including the inability to absorb calcium, heart rhythm issues related to reduced magnesium absorption, and increased risk for certain infections. And some people simply do not want to be on medication for the rest of their lives.

When medications and lifestyle changes are exhausted and no longer effective (or only partially effective) at controlling a patient's symptoms, surgical options can correct the problem and greatly decrease, if not eliminate, symptoms and need for medication. For most patients, surgeons are able to make 5 very small incisions in the abdomen (each ½ centimeter wide) and fix the underlying cause in approximately 1 ½ - 2 hours. During the surgery, they are checked with an endoscope to see down the esophagus into the stomach to ensure the best result has been achieved. Patients awake from general anesthesia with no catheters or drains, begin a liquid diet on the same day, and are generally discharged home the next morning. It is recommended that the patient stay on a pureed diet for two weeks, after which time they can return to normal healthy eating.
Approximately 90% of patients report complete resolution of their reflux symptoms and no longer have a need for medication. In a study that followed patients 5 years after surgery, the patients reported fewer heartburn and belching episodes, and generally had better feelings of health and vitality as compared to medical therapy.

Thankfully, advances in minimally invasive surgical techniques have given patients more and better options to find relief from their symptoms. If you're suffering from heartburn or reflux, it's best to see your doctor and discuss your options so that together, we can find the best treatment for you.

If you've ever had issues with sciatica before, there's no doubt you'll contest that it may be some of the worst pain of your life. In fact, some women have said that sciatic pain is worse than childbirth! Typically, the hallmarks of sciatica are pain and numbness that radiate down the back of the leg, often below the knee. Since sciatic pain is often felt along the course of nerves and their branches, the symptoms are felt mainly in the legs, even though the problem originates in the lower lumbar region of the spine.

It is important to know that sciatica is not a diagnosis in and of itself. Rather, it is a symptom of an underlying medical condition, often an offshoot of a disc problem, with a piece of the disc pressing on your sciatic nerve, irritating it and causing it to act up. In nine out of 10 cases, this is the cause, particularly in younger patients.

Sciatica symptoms (e.g., leg pain, numbness, tingling, weakness, possibly symptoms that radiate into the foot) are different depending on where the nerve is pinched. For example, an irritated nerve can cause weakness in extension of the big toe and potentially in the ankle. Typically, sciatica sufferers experience constant pain only in one side of the buttocks or leg, they may have pain that makes it difficult to stand or walk, and they may be worse when sitting.

So, you may be wondering... who is the unlucky one to get sciatica? The answer is that the incidence can vary, but it greatly increases in middle age. It rarely occurs before age 20, but can, and the probability of experiencing sciatic pain from a disc peaks in the 50s and then declines. Often, people do not recall a specific event that caused their symptoms.

Typically, the diagnosis of sciatica can be made by patient descriptions of what they've been feeling and a physical examination. However, an MRI can provide direct evidence of a disc problem and confirm or deny that diagnosis.

The vast majority of people who experience sciatica get better within a few weeks or months and find pain relief with conservative treatment options. Conservative treatment a catchall term for everything but surgery used to emphasize inactivity or even bed rest.

However, now we generally advise patients to keep up their daily activities as much as possible. Pain relievers, usually standard non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen, are often prescribed. In addition, physical therapy can help strengthen muscles in the abdomen and around the spine, which may take some pressure off the discs. If none of this works, corticosteroid injections, which have a strong anti-inflammatory effect, are a non-surgical option.

When sciatica pain is severe and debilitating, then a surgical option may be necessary to relieve the underlying disc problem. Fortunately, today, there are minimally invasive surgical options for treating this issue, many of which are available right in your own community. With minimally invasive surgery, smaller incisions are made, and that means patients recover faster, with less pain, blood loss and disruption to their daily lives.

If you're suffering from sciatica pain, the biggest takeaway is don't suffer in pain for an extended period of time. Get a leg up... and save yourself from sciatica!

This column was written by orthopaedic physician, Dr. Jeff Pravda. Dr. Pravda is a MidState Medical Center-affiliated physician who practices with Comprehensive Orthopaedics, with offices in Meriden, Wallingford, Cheshire, and Southington.

You're cutting your lawn and suddenly you realize you've run over a hornet's nest. You know what's coming next and you see the swarm rise up. You run! You think you've escaped but then you feel that dreaded sting on your upper thigh. Too late...you got tagged by the quickest hornet of the bunch.

Knowing what to do if you get stung can lessen your pain and, if you're very allergic, can save your life.

Late summer and early fall see an increase in the activity and aggressiveness of bees, wasps and hornet not too mention an increase in the outdoor activities of humans. Like most insects, bees, wasps and hornets generally don't want a fight, unless you bother them or their nest. The best prevention is to avoid disturbing them altogether. Despite this, one million stings occur each year in the United States. Most are only annoying and painful but 3% of those results in potentially serious reactions.

The first thing you should do is remove the stinger, if it is still present. A bee's stinger is attached to a small sac that contains the bee's venom. This sac can still actively inject venom into your skin for up to a minute after the sting. Honey bees stingers have barbs in them, so they tend to rip away from the bee and stay in you. Hornets, yellow jackets and wasps have smoother stingers, so they can sting repeatedly and are less apt to leave a stinger. It doesn't matter how you remove it, just that you do it quickly. Studies have dispelled the myth that scraping the stinger away is better than just grabbing it.

Ice or cool soaks should be applied as soon as possible, in conjunction with cleaning the site of the sting with soap and water to prevent infection. You should also elevate the part of the body that got stung.

All bee stings cause some degree of an allergic response, from mild to life-threatening, so unless there is a reason you cannot take benadryl, you should. Just remember that benadryl can make you sleepy so take this into account if you're tired, driving or if you've been drinking alcohol.

Mild allergic reactions take the form of pain, itching, swelling and redness. More severe allergic reactions can cause itchiness all over and hives. The most severe, life-threatening reactions cause anaphylaxis. Anaphylactic reactions can result in closing of the throat, closing of the lung tubes, and a dangerous drop in blood pressure. Death can occur.

Allergic reactions are your body's way of defending itself against foreign invaders. Allergic reactions have "memory." Once you are exposed to something, the body prepares itself to react to the foreign invader the next time it encounters it. Sometimes these reactions "over-react" and release too many chemicals putting you in discomfort or danger. It follows then that with each exposure to a bee sting, the greater the chance for an increasingly severe reaction and the shorter the time-frame between stings, the greater the risk. Still, overall, out of the estimated one million stings per year, only 3% result in severe reactions. Most severe reactions will take place within the first 4 hours of a sting with 50% of deaths occurring within 30 minutes.

While it is possible to have a fatal reaction to a bee sting with no previous stings, the norm is to have a severe, generalized reaction after a serious of increasingly more severe reactions. If this describes you, you should discuss this with your physician.

There are some simple steps you can take to avoid getting stung, no matter what your reaction. Avoid disturbing them or their nests. Avoid wearing bright colors or perfume when outside. At a picnic, check the edge of your soda can before taking a sip. Shake out clothing that you've left outside.

On another note: don't forget to enjoy the flowers they pollinate or the honey they produce!

Most Americans today recognize the value of partnering with a good primary care provider (PCP) as an effective preventive measure against potential disease. This relationship begins with a wellness or preventive exam, what some call their "yearly physical."

During the first of such visits, a complete patient and family medical history is taken and discussed with the patient. A detailed exam follows, which will be performed yearly from then on. Over time, a partnership develops between doctor and patient with the shared goal of ensuring optimum patient health. From my perspective as a PCP for adults, this goal is best achieved by not only applying my medical skills and expertise but also by building my patient's trust.

Who should have the annual visit? It might be best to start with who doesn't need to schedule wellness or preventive exams. Healthy individuals in their twenties, thirties or even forties who do not have a family history of serious illnesses such as breast, gynecological, colon or lung cancer do not necessarily require this routine yearly checkup, and may generally be seen at 3 year intervals. The standard of when wellness and preventive visits should routinely begin for healthy men and women is around age 50. In general, women should have an annual gynecological exam with Pap smear beginning at age 21.

It is important to differentiate between disease management and preventive care. For individuals with conditions such as obesity, diabetes, hypertension, etc., the wellness visit offers opportunity for monitoring, observing changes and counseling. As such, it can be seen as part of disease management. These patients, whether young or old, should be scheduled for this yearly visit.

But let's say a patient presents for their wellness visit without signs of anything. That's when we're providing preventive services. If, however, that same patient says, "I have a cough, and I've had it for three months," we are now in the realm of dealing with a symptom of disease and we move beyond preventive services. Further investigation and treatment may be required, either by the PCP, or in consultation with a specialist.

Expect a thorough process In my practice, a comprehensive checklist of services is performed during the wellness or preventive visit. This includes:

Yearly updating of immunizations as well as counseling on the importance of receiving these immunizations

Taking vital signs and blood pressure; monitoring of hypertension (high blood pressure) and counseling on ways to decrease it

While we regularly order screening tests for the above-mentioned diseases, patients are often under the impression that more tests exist that they should have. In fact, there are best practice guidelines published by our medical societies that determine the benefits of certain screening tests. Just because a test exists, does not mean it should be utilized for screening. False positive results for many tests, such as the ovarian blood test (CA-125), often lead to unnecessary, expensive treatment with potential physical harm. These tests would not be recommended.

"Hands on" The final but equally important part of the wellness and preventive exam is the physical. Going from head to toe, the physician closely examines the patient to evaluate the health of the body's organs and systems, and to catch any problems not yet detected or mentioned by the patient. Again, the checklist is extensive:

Examining the eyes, ears, mouth and throat

Feeling the neck, thyroid and lymph nodes for lumps or swelling

Listening to the heart and the lungs, and feeling the arterial pulse points in the neck, and all extremities

Examining the breast tissue in both women and men

Feeling the liver and spleen

For women, performing a pelvic exam; and for men, a genital and prostate exam

Performing a rectal exam and fecal test for patients not up-to-date on their colonoscopy

Examining the skin for signs of cancer

A team to count on The wellness and preventive visit ultimately is a line of defense set up to promote health, and prevent illnesses. We are fortunate, at a time when so many people are seeking good, regular primary care, to have highly trained advanced practice nurses (APRNs) and Physician Assistants (PA's) who are well trained to perform the wellness and preventive exam services. As the physician, my role continues to be seeing and examining patients, supervising a great team of medical professionals, and building partnerships with my patients based on their trust in our ability to provide the highest level of primary care.

Tennis elbow is a common condition that occurs on the outside of the elbow joint. It occurs over the bone of the distal humerus, called the lateral epicondyle. A professional name for tennis elbow is lateral eqicondylitis. Tennis elbow is more common than people believe and is a nagging injury that is slow to heal. In severe cases, it requires treatment with a physical therapist, other medical professionals, and often times a surgeon. Tennis elbow, while bearing the name of our favorite sport, is not always due to playing tennis. Other causes exist such as lifting weights, a heavy brief case, using hammers, twisting a screwdriver, opening jars or anything that involves a power grip. Typically, the muscles that extend the wrist to enable one to have a stronger grasp and increase strength in their hand originate off the lateral elbow and can tear with a very strong use of the hand.
Specifically, the muscle that is most commonly injured is the extensor carpi radialis brevis (ECRB).

Tennis elbow can be chronically painful and can last for an extended period of time. It is a degenerative process where the tendon gradually breaks down and then will suddenly tear. Scar tissue forms and, as it is beginning to heal and get stronger, the person will do a physical activity with his hand that involves a forceful grip and the muscle tears again. Each time it tears, vascularity gets less, the scar tissue gets greater, and the healing is more difficult to achieve.

Tennis elbow is diagnosed by a clinical exam. It is painful to palpation over the lateral elbow at the most prominent bone, of the lateral epicondyle. This is where the write extensors originate. The pain may go down the arm, but typically, it is isolated to that bone and into the proximal portion of the muscles where they originate off the bone. The pain can be quite exquisite and give the sensation of a "dead arm" with forceful contraction of the muscles in the hand.

The treatment for tennis elbow is multifactorial. Typically, the easiest form of treatment is to use nonsteroidal antiinflammatories. With activity, it is beneficial to warm up slowly and to ice afterwards. A tennis elbow brace can be very useful. This is a strap that wraps around the arm just below of distal to the torn tendon. This causes the tendon to reduce its excursion and allows function without further aggravation. It allows people to participate in sports with this condition. In severe cases, a cortisone shot may be required. With physical therapy, ultrasound, massage and gradual strengthening and stretching of the muscles is recommended. If this does not work, then surgery should be considered, although, this is needed in only approximately 3% of the cases.

In severe or refractory cases an MRI may be indicated. This will show the torn tendon, but is not always useful in terms of adding to the treatment. X-rays are usually normal.

Alternative forms of treatment include an ultrasound, friction massage, cortisone shots, and an injection of platelet enriched plasma (a relatively new treatment), all of which can reduce inflammation. All of these modalities make therapy more effective.

Cancer. A word that can silence a room and bring tears to otherwise dry eyes. It is also a word that can generate sincere gratitude from survivors, draw families closer together, bring about a person's life purpose, and can even have NFL teams showing their support by wearing pink ribbons on their jerseys. Most of us either know someone who has/had cancer or have battled it personally. We see information about it in the movies, in books, on television. There are blogs, support groups, seminars, websites and news articles that speak to this disease. We learn of new therapies and scientists who continue to search for new medication to help in the fight.

One thing is certain about this one word, cancer, there are many people who come together and dedicate their career to find a way to help us live longer, better and healthier lives. These are people on the front line, like your cancer doctor (oncologist), or those in the lab, attempting to provide us with options for treating this disease. Although we have many people who have been successful in their struggle with cancer, it can be very difficult to treat. Many oncologists provide you with options using the standards of care. The standards of care are the best known treatments for a particular type of cancer. More and more, another option your oncologist may present to you is a cancer clinical trial using a therapy that is being researched.

Many people cringe at the thought of research. The term "guinea pig" often comes to mind. Although the FDA has made great strides in the training of medical personnel, providing guidance and policies to protect patients and in some extreme rare cases discipline those found to abuse the system. Research brings together the brightest minds in an effort to make life just a little better. However, that effort can take 10-15 years for a particular therapy. The process timeline starts with scientists formulating an idea about a medication to treat a specific cancer; laboratory studies determine its effectiveness and safety; and then after many more years a clinical trial is proposed and carried out.

Many would be surprised to know that all medications that are currently prescribed to patients have been through the rigors of a clinical trial. Be it a medication for a headache or chemotherapy for breast cancer, research was conducted to provide information necessary for it to finally become available to friends, family and our children.

Today many people seek out clinical trials as an option in their plan of care, not only to enhance their life, but to provide needed information to researchers for the younger generations that may develop the same cancer. Many clinical trials provide a standard treatment plus an additional study medication. Patients in FDA approved trials are never given a treatment that may be inferior to what is already available.

In addition, it is very important to researchers that everyone offered a clinical trial is comfortable participating. Patients will go through an "informed consent" process safeguarding that they fully understand the details, risk and potential benefit. Patients are always given the option to decline participation without any adverse consequence to their care. Conversely, not all patients will be eligible for clinical trials. Prior to opening a trial to the public, strict and specific guidelines are established that either include or exclude patients based on a variety of factors. This helps to ensure that the information discovered is clean and reliable.

There may also be different types of trials available to a patient. This may have to do with how advanced a drug is in the development process. Phase I clinical trials test drugs in humans soon after being tested in the laboratory and are deemed safe. This is the very earliest phase of drug development and helps to establish the proper dose of drug. Phase II clinical trials determine how well the drug works, if they are effective enough the process will move on to a much larger scale. Phase III trials, which have the largest number of participants, are where researchers attempt to prove the benefit of a new drug or therapy against the standard of care. If the drug does well after this phase, then it goes to the FDA for final review and approval.

Although research is a very complex specialty, clinical trials are very important for the ongoing success of our quest to treat and one day, cure cancer and other diseases. While they are important for this mission, it is equally important that they be carried out safely and with the free will of participants. If you know someone or are someone given the option to participate in research think about the benefits, understand the risk and always ask questions until you fully understand all the options. Although a clinical trial may be a great opportunity, it may not be for everyone.

"Bob, you were up all night coughing... and you kept me up too. Will you please go to the doctor and get some antibiotics."

How many times have you heard this?

Odds are, you have, and while there are some very good reasons to be seen for a cough we need to discuss the most likely diagnosis and more importantly, the unlikelihood that antibiotics are going to be needed.

Cough is the most common reason why people visit their primary care doctor, and in an Urgent Care setting, this is no different. More often than not, the diagnosis is acute bronchitis and more often than not, patients believe that they really, really need an antibiotic. They usually don't.

Bronchitis, or a "chest cold," is an infection and inflammation of your bronchial tubes, the passageways that bring air into your lungs. Go ahead and feel your breastbone or sternum. Underneath that bone are your bronchial tubes. There is a main one in the center and two that branch off into each of your two lungs. When you get a cold, these tubes become infected and irritated. That causes mucous production and the persistent, annoying cough that keeps you and your spouse up.

And that stinks! No one wants to cough all the way through their meeting, getting branded the office Typhoid Mary. Persistent coughing sometimes hurts, it's gross and may keep you from doing sports or other activities that you enjoy. You want to feel better... and now. Sounds like an antibiotic is in... whoops wait a minute Bob.

The truth is approximately 90% of cases of acute bronchitis are caused by viruses. Antibiotics don't kill viruses. They kill bacteria. Despite this fact, about two-thirds of patients who are diagnosed with bronchitis are unnecessarily prescribed antibiotics. This isn't a good thing. Overuse of antibiotics can lead to numerous problems, both for you and the community. When you take an antibiotic when there isn't indeed a bacterial infection, you expose what bacteria your body naturally has around to the drug. Bacteria may be small but they're smart. They can develop resistance to the drug and become "superbugs" capable of defeating more antibiotic drugs.

So why do we physicians sometimes prescribe antibiotics for bronchitis when we know they aren't needed? Well, we're getting better at not doing it but many patients believe that they need antibiotics and sometimes we want to be able to meet the patient's expectations. However, recent studies have shown that if a physician takes the time to explain bronchitis and its causes, most patients are satisfied to NOT receive an antibiotic prescription. That's a good thing.

So then, why go to the doctor in the first place? Excellent question.

First of all, there are many things that can cause a cough, everything from a simple cold to very serious conditions. But common things are common and bronchitis is the most usual diagnosis. You would want to see a doctor to determine this and also to rule out that you don't have pneumonia or the flu. There are also some instances in which an antibiotic for bronchitis is warranted. The nurse and doctor will make sure that you are not having trouble breathing and that your "oxygen level" is good. If the physician hears pneumonia or suspects it a chest x-ray,an antibiotic may be required.

If the physician feels that you have a viral bronchitis, he or she may discuss with you the expected duration of your symptoms and things that you can do to feel better. Some physicians recommend cough medicine, either over-the-counter drugs or the more potent, narcotic based cough medicines, although there seems to be a lack of good evidence for their use in the medical literature. If you have wheezing, often times an inhaler will be of benefit.

How long can bronchitis last? Most patients will have the cough for less than two weeks but 26% of patients will have the cough after two weeks. Some will have the cough for several weeks. This is hard to hear and almost as hard to tell a patient. But the human body is an amazing machine that fends off nasty organisms all the time and viruses "burn" themselves out.

"Good news Bob. Based on your history and your exam, I don't think that you have pneumonia or any other serious condition. It sounds like bronchitis. I think that this cough medicine may help quiet your cough at night. Hang in there but please let me know if anything changes."

Prediabetes is when blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes. It is also referred to as borderline diabetes, impaired glucose tolerance and/or impaired fasting glucose.Before people develop type 2 diabetes, they are first in a prediabetic state. According to national diabetes data from 2011, about 26 million have diabetes and 79 million people in the United States have prediabetes. If left untreated, diabetes can progress and lead to serious long term complications such as heart disease, stroke, nervous system and kidney damage, blindness, foot ulcers and amputation. Prediabetes increases the risk for heart disease, such as heart attack and stroke. Most people with prediabetes do not have any symptoms and by the time they are symptomatic, the condition has progressed to diabetes.

Cause of Prediabetes:Insulin resistance, a condition in which the body cells do not use insulin properly. Insulin helps cells use blood glucose for energy.

Who should get tested for prediabetes:In individuals without risk factors for diabetes, testing should begin at the age of 45 years old and even earlier in those with increased risk. Risk factors for diabetes include being overweight with a body mass index equal to or greater than 25kg/m2, family history of diabetes in a first degree relative, physical inactivity, history of gestational diabetes or having a baby weighing nine pounds or more at birth, high blood pressure, vascular disease, polycystic ovarian syndrome, metabolic syndrome, high cholesterol and high risk ethnic groups such as Asian-American, African American, Hispanic, Native American and Pacific Islanders.

Screening tests:There are three different tests to determine if you have prediabetes

Fasting plasma glucose -This blood test is done after fasting overnight or at least eight hours. A blood level between 100-125mg/dl is considered prediabetes or impaired fasting glucose; 126mg/dl and above is diabetes.

Oral glucose tolerance test -Here, blood glucose is checked in a fasting state and again 2 hours after drinking a 75gram glucose rich drink. Two hour blood glucose values between 140-199mg/dl is considered prediabetes or impaired glucose tolerance, while 200mg/dl and above is indicative of diabetes.

Glycosylated hemoglobin/A1c test -This blood test gives the average amount of glucose in the blood over past the three months. It is very convenient as it does not require fasting. Values between 5.7-6.4% are considered prediabetes, whereas 6.5% and above is diagnostic of diabetes. Certain conditions can make the A1c test inaccurate, such as pregnancy or having an uncommon form of hemoglobin.

The diagnosis of diabetes must be confirmed by repeating the test which was abnormal on another day for confirmation. Higher values convey higher risk than lower values. If the tests are normal, it should be repeated in three years, but for those that have increased risk for diabetes, the test should be performed yearly.

Management of prediabetes/Prevention of progression to diabetes:

Approximately 25% of people with prediabetes progress to diabetes over 3-5 years. A diabetes prevention program study has shown that people with prediabetes can prevent the development of type 2 diabetes by making changes in their diet and increasing their level of physical activity. They may even be able to return their blood glucose levels to the normal range.

The American Diabetes Association recommends lifestyle modification as the primary intervention. Research shows risk for type 2 diabetes can be lowered by 58% by lifestyle modification. That is, smoking cessation, diet control, weight loss of 5-10% of body weight, moderate intensity exercise of thirty minutes daily for at least five days a week, such as brisk walking. The thirty minute exercise can be split into smaller sessions if it cannot be done at one time. Drug therapy may be helpful in preventing type 2 diabetes in high risk patients in whom lifestyle interventions fail or are not sustainable.

The American Diabetes Association also recommends consideration of metformin for diabetes prevention in individuals at highest risk for developing diabetes, such as those with both impaired fasting glucose and impaired glucose tolerance and are younger than 60 years of age and with a body mass index equal to or greater than 35kg/m2 or who have additional risk factors such as a family history in first a degree relative, elevated triglycerides, reduced HDL, high blood pressure and A1C greater than 6.0%.

While studies have shown that drug therapy may delay the development of diabetes, lifestyle changes work better and are twice as effective as taking a pill.

First, let's be sure you know about the Shingles disease. Also known as Herpes Zoster, Shingles is caused by the same virus that causes chickenpox. This virus can live and remain inactive in nerve roots within your body for many years. If it becomes active again, usually later in life from a stressor, it can cause Shingles. Older adults have difficulty defending against viruses. There are approximately 1 million cases of Shingles in adults over 60 years old each year.

The first signs of Shingles are often felt and not seen. This is why it is hard to diagnose. When diagnosis is more than 72 hours after symptoms, then treatment is usually not effective. What are some of those signs? Some symptoms include itching, tingling, burning, pain, and a rash of fluid filled blisters. Generally these occur only on one side of your body or face. Blisters may take 2-4 weeks to heal.

The after effects of Shingles can be pain that is quite severe. For most people, the pain from the rash lessens as it heals. But for some, the pain can last months to years or even permanently. "Post-herpetic neuralgia" as it is called damages the nerves. Skin is so sensitive that even the touch of clothing or sheets can be painful. Other long term problems from Shingles can be infection of skin, scarring, muscle weakness, or loss of vision or hearing. These after effects can sometimes be disabling.

The Vaccine called Zostavax is made by MERCK and was approved in 2006. It's used to prevent Shingles in adults over age 50. The vaccine cannot treat Shingles or the nerve pain that follows. You can get the vaccine whether you remember having chickenpox or not. You can get the vaccine if you have had a Shingles infection in the past. However, the vaccine is not 100% effective. If you do get Shingles after the vaccine, it can lessen the intensity of the disease and it can help prevent the nerve pain afterwards. Protection beyond 4 years is not known. The need for revaccination is not yet known either.

The vaccine is given as a single shot and is a live virus. You should not get the Zostavax vaccine if: you are allergic to Gelatin or Neomycin, have a weakened immune system (i.e., cancer, rheumatoid arthritis), are sick with a fever, have an untreated illness like Tuberculosis, are on high dose steroids, are pregnant or plan to become pregnant. You should have other vaccines 4 weeks apart from this one, particularly the Pneumonia vaccine. Some side effects can occur from this vaccine as in any vaccine. The main ones are redness, pain, itching, swelling, warmth, bruising at the injection site, and headache.

How is it paid for? Most commercial insurance plans do cover the vaccine. You should contact your insurance provider to find out. However, Medicare Part B (which covers most other office vaccines) does not cover the Shingles vaccine. Medicare Part D plans do cover the Shingles vaccine. The amount of copay for vaccination varies according to your prescription plan.

I hope this sheds light on this fairly new vaccine. Our thought for the future is this: The Varicella vaccine (chickenpox vaccine) for children has reduced natural infection by 75-80%. Will the Shingles vaccine affect the decline of Shingles? There are no trends yet but let's hope so.

Headache is a very common medical complaint, both in emergency rooms and physicians offices. Most of these are not due to any worrisome cause but do require chronic management. There are a number of things patients themselves can do to help keep their headaches in check.

The vast majority of headaches are not due to any life-threatening process. Migraine and tension headaches are by far the most common. Migraines, when at full severity, have disabling throbbing head pain in half the head (the word "migraine" is derived from Latin meaning "half the head"), with severe sensitivity to light, sound, and other stimuli, sometimes causing nausea and vomiting. There can in some people also be bizarre visual auras which precede the migraine. Tension headaches are less severe, pressure and "vice-like," typically in a headband pattern around the skull.

With a patient in the office complaining of headache, a physician's first job is to sort out which few of these headaches are not just migraines or tension, and require further evaluation. This is done by recognizing certain red flags, which include things such as abrupt onset of the worst headache of life, headaches with certain types of symptoms such as weakness, and onset of headaches older than age fifty.

Once a physician is satisfied that the headaches are not due to any severe process, the next step is treatment to reduce symptoms. This can include a variety of daily and as-needed medications, and a lot of the medical care of headaches revolves around adjusting some of these medications. This is, however, only a part of headache management and the non-medication therapies can be just as important as what pills people take.

There are a variety of lifestyle changes which can be helpful. Regular sleep is important, and while most people would recognize that lack of sleep might be contributing to headaches, is also the case that people with migraines should not oversleep. Similarly skipping meals and particularly getting dehydrated can bring out headaches. All of these things play to the same theme - anything that throws the body's balances off-kilter can provoke worsening headaches. This is not to say that doing all of these things perfectly would completely prevent headaches, it's just that not doing them (such as not eating anything or drinking anything all day, and then staying up all night) is just asking for a severe headache.

Stress often plays a large role in headaches, and while we cannot live stress-free lives, having good stress management and relaxation techniques can make a very big difference. Having someone to talk to about problems, whether it is a professional counselor or just a close friend or family member, can be invaluable when faced with stressful circumstances.

With the help of a physician a patient can use medications and other options to help control their headaches. Lifestyle changes and stress management techniques empower the patient to be able to gain some control of the various factors impacting their headaches.

This column was written by MidState Medical Group neurologist, Justin Montanye, MD, who practices with the MidState Medical Center Neuroscience Center.

The kidney functions by filtering blood and removing the waste products created when your body breaks down food. The kidneys, in addition to filtering blood to remove waste, also regulate electrolytes and fluid volume. They also play a role in regulating blood pressure.

Nephrologists are medical doctors who specialize in kidney disease. Nephrologists are also specialists in hypertension (high blood pressure) and can help your primary care doctor achieve optimal blood pressure control.

Many diseases, both acquired and inherited, can damage your kidneys. Most people with kidney disease have no symptoms, and are unaware they have kidney disease until the disease is advanced. The only way to detect problems with your kidney function is through routine blood work and urine studies. It is also important to know if kidney disease runs in your family, as this puts you at increased risk for kidney disease.

Most people who develop kidney disease worsen over time. There are usually no symptoms in the earlier stages of kidney disease, but as it progresses it can cause one to become sick due to increasing amounts of waste products building up in the blood. Advanced kidney disease can cause nausea, vomiting, poor appetite, weakness, tiredness, itching, muscle cramps, anemia, high blood pressure, puffiness around eyes, and increased swelling of the hands and feet. In addition, several complications from kidney disease can develop, such as blood pressure that is difficult to control, anemia, weak bones, and malnutrition.

If kidney disease goes undetected, you are at risk for developing end stage kidney disease. This can cause death if not treated and may require the help of a machine to clean and filter the blood. This is what is known as dialysis. Dialysis involves regular blood cleaning treatments three times per week. This method, as well as kidney transplantation, are two types of renal replacement therapy.

How common is kidney disease?

More than 26 million American adults have Chronic Kidney Disease (CKD), which means 1 in 9 adults are affected. Millions of others are at risk for kidney disease, including individuals with high blood pressure, diabetes, the elderly and those with a family history of kidney disease. Kidney disease is a growing problem in America, in part due to lifestyle choices and the rising obesity epidemic. The two most common causes of CKD are hypertension and diabetes mellitus.

How does hypertension cause kidney disease?

High blood pressure makes the heart work harder and over time can damage the blood vessels throughout the body, including the kidneys. If the blood vessels in your kidneys are damaged, they are less able to remove waste products and excess fluid from the body. The extra fluid in the blood vessels can raise the blood pressure even further and can lead to dangerously high pressures, which in turn further harms the kidneys.

How does diabetes cause kidney disease?

When there is too much sugar in the blood that filters through your kidneys, they become overworked. Excess blood sugar can damage the tiny blood vessels in your kidneys, and over time, can cause excess protein in the urine.

How do you monitor for kidney disease?

See your primary doctor and get routine blood work which includes tests for kidney function (Blood Urea Nitrogen level and Creatinine level) and urine studies (Urine Protein level) on a yearly basis. If abnormalities are detected, your primary care doctor should refer you to a nephrologist for further evaluation. People who are at increased risk of developing kidney disease are the most important people to screen. They include patients over 65 years of age, those who have hypertension, a family member who has had kidney disease, African Americans and Hispanic Americans.

Early detection is crucial because identification of kidney disease can help prevent the progression of kidney failure and avoid the need for hemodialysis and kidney transplant.

Urinary incontinence is defined as "the complaint of any involuntary loss of urine." Many women suffer from this silently, thinking it is something that they have to live with and cannot fix. Some women will wear and change multiple pads daily. In fact, there is treatment available. Identifying signs and symptoms is the first step.

Urinary incontinence is classified in the following way.

Stress urinary incontinence is the complaint of involuntary leakage on exertion (i.e. heavy lifting) or on sneezing or coughing.

Urge urinary incontinence is the complaint of an involuntary leakage accompanied by or immediately preceded by a strong urge to void.

Mixed urinary incontinence is the complaint of an involuntary leakage of urine associated with a strong urge to void and also with exertion, sneezing, or coughing.

Overflow incontinence is the complaint of an involuntary leakage of urine associated with incomplete bladder emptying. These patients have a full bladder and are retaining urine.

Evaluation begins with a thorough history and physical exam. Part of the history is an assessment of the frequency and severity of incontinence, its degree of bother, and its effect on quality of life. Previous surgical history is important if it involves the pelvis or a previous surgical repair of incontinence. A urinalysis and urine culture are also performed so that infection can be ruled out. Infection can cause transient incontinence if not recognized and treated.

It is also suggested that patients keep a voiding (and incontinence) diary to observe patterns in their own environment and during normal daily activities. This insight can point to behavioral changes which may be helpful in alleviating the incontinence. In addition, urodynamic testing is done in the office to evaluate bladder function and guide treatment options, especially in women with mixed urinary incontinence. Bladder sonograms are occasionally used to evaluate the bladder's ability to empty completely. Although rare in women, urinary retention can cause overflow incontinence. Your urologist will review the evaluation tools necessary to arrive at the correct diagnosis in your individual case.

Medical and surgical treatments are available with different success rates.

Stress incontinence can respond to physical/biofeedback therapy as well as surgical therapy, depending on how severe the symptoms are.

Urge incontinence can respond to medication. If medical therapy fails, there is surgical therapy available for urge incontinence.

Mixed incontinence can respond to medical or surgical therapy, depending on which component (stress or urge) is more severe.

Overflow incontinence needs to be identified and treated in order to prevent deterioration in kidney function. Treatments for overflow incontinence involve adequate drainage of the bladder.

Your urologist can work with you to identify your signs and symptoms, classify your incontinence, and identify your personal risk factors. There is no need to be embarrassed about incontinence. It is quite common, and a plan of treatment can be drafted and implemented to help you. Personal habits can be analyzed and changes recommended based on your type of incontinence. Together, we can put you on the road to achieving urinary continence and help you remain dry.

There is compelling evidence that overweight people are at increased risk of a variety of health problems, including type 2 diabetes, hypertension, dyslipidemia, coronary artery disease, stroke, osteoarthritis and certain forms of cancer. In addition to affecting personal health, the increased health risks translate into an increased burden on the health care system. Obesity can therefore be considered to be one of the most important chronic diseases facing Americans of all ages.

The limited long-term success of behavioral and drug therapies in patients with severe obesity has led to recommend bariatric (weight loss) surgery as a choice in adults with clinically severe obesity (Body Mass Index (BMI) > 40 or > 35 with severe obesity-related disease) when lifestyle interventions are inadequate to achieve healthy weight goals.

Sleeve gastrectomy is a new surgical weight loss procedure in which the stomach is reduced to a sleeve or tube with a banana shape (about 20-25% of its original size). The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically, meaning that it is minimally-invasive and is not reversible.

Laparoscopic sleeve gastrectomy is a restrictive operation that reduces the size of the stomach to 80-120 mL, permitting the intake of only small amounts of food leading to a feeling of fullness earlier during a meal. More recently, however, it has been suggested that decrease of ghrelin levels may also contribute to the success of the procedure. Ghrelin, which is thought to be a hunger-regulating hormone, is mainly produced in the stomach. By removing this part of the stomach during a sleeve gastrectomy, the majority of ghrelin-producing cells are removed, thus subsequently reducing hunger.

Sleeve gastrectomy patients can lose, on average, 55% of their excess body weight. Laparoscopic sleeve gastrectomy does not involve a foreign body implantation or adjustments such as the gastric banding, thus minimizing the after care and complications related to the device.
Sleeve gastrectomy also differs from gastric bypass in that it does not "disrupt" the digestive tract; therefore, there is no need for medication changes and post operative complications such as severe malnutrition, vitamin deficiency and dumping syndrome are minimized.

As with any surgery, the benefits should outweigh the risks. With good information, commitment and discussion with the medical team, the right surgical procedure should be tailored to each individual and should be the one with the most minimal risks and clear expected outcome.

To learn more about the Weight Management Program or a free Weight Loss Surgery Information Seminar, visit www.midstateweightloss.org.

Dr. Benbrahim is a general surgeon with the MidState Medical Group Surgical Specialists and is medical director of MidState Medical Center's Weight Management Program.

The Pap smear is a test used to find changes in the cells of the cervix that could lead to cancer. In 1948, more than 17,000 women in the U.S. died of cervical cancer. In 2009, that number was down to 4,070. Half of all women diagnosed with cervical cancer have never had a Pap smear, and 10% have not had one in the past 5 years. Therefore, it is important that most women have Pap smears on a regular basis.

The cervix is the lowest part of uterus. The cells at the bottom layer of the cervix move to its surface. It is during this process that these cells can become damaged or abnormal. These abnormal cells may lead to cancer. The abnormal changes are referred to as dysplasia. In contrast to lowgrade dysplasia, high-grade dysplasia is a precursor to cervical cancer and requires treatment. The Pap test is a simple test that can detect abnormal cervical cells. Routine Pap tests help decrease the chance that abnormal cells are missed.

Human papillomavirus (HPV) is the main cause of cervical cancer and abnormal Pap tests. It is sexually transmitted, and a woman's immune system can usually clear the virus; however, in some women HPV will persist. Teenagers do not need Pap tests unless they have been sexually active for 3 years. A teenager's immune system is usually able to clear the virus, and reverse any abnormal changes of the cervix, without any medical or surgical intervention. Only 0.1% of cervical cancer occurs before age 21, therefore it is recommended that women begin getting Pap smears at age 21.

Studies have shown that women should have a Pap test every 2 years. If over 30, a woman with 3 normal Pap tests in a row may have Pap tests every 3 years as long as she does not have a history of highgrade dysplasia, she is not infected with HPV, her immune system is not weakened, she does not have a new or more than one sexual partner, and she was not exposed to diethylstilbestrol before birth. Other risk factors for the progression of disease are a compromised immune system and cigarette smoking.

It is important to differentiate aPap test from a pelvic exam, and therefore, a woman should still visit her gynecologic provider annually for well-woman care and a pelvic exam to evaluate all pelvic organs. It is unclear when a woman can stop having Pap tests. Some experts say ages 65 or 70 after 3 normal results in a row in the past 10 years. Again, if risk factors exist then routine screening is in order.

If you have had a hysterectomy, talk to your doctor about whether you still need routine Pap tests. This may depend on why you had a hysterectomy, whether your cervix was removed, and whether you had a history of cervical dysplasia.

If you are 30 and over, you can be tested for HPV at the time of your Pap. A woman this age who tests positive for high-risk HPV, even with a normal Pap result, is at higher risk of developing cervical dysplasia.

If she has a normal Pap and is negative for high-risk HPV, the chance that she will develop dysplasia in the next 3-5 years is very low, and she does not need these tests again for another 3 years. A woman under 30 does not need HPV testing routinely as it is a very common infection in this age groupand usually goes away on its own. There is no medication available to get rid of the HPV virus; however, vaccines are available for women ages 9-26 which provide immunization against common HPV strains.

An abnormal Pap smear result does not mean you have cervical cancer. It only means that abnormal cells have been found. Progression to cervical cancer is very slow and may take years, and often, these abnormal cells go away on their own. However, you will likely need more testing like a colposcopy which is done in the office. The results of this test may indicate pre-cancerous changes or cancer. There are several techniques available to remove the abnormal tissue. After treatment, you will need follow-up testing on a more-frequent basis. Women with a history of treatment for high-grade dysplasia or cervical cancer remain at risk for recurrence for at least 20 years. Once again, the importance of routine Pap smear cannot be stressed enough for this very effective screening test.

They say that time flies. This is no more apparent to me than when I contemplate the changes that have occurred in the care of cancer patients over the course of my career (22 years and counting). Not so long before completing my oncology training, cancer patients were being treated with mutilating surgery, primitive radiation therapy techniques, and poisons referred to as chemotherapy. In fact, the very first chemotherapy agents were derived from poisonous mustard gas used in World War II. Not that we have conquered the beast called cancer, but we as a medical profession have made substantial advances in the treatment of malignant disease, with corresponding improvements in survival anticipated for most cancer patients diagnosed in 2010. Surgical techniques have improved, with the development of laparoscopic and robotic procedures which have led to less invasive surgery and fewer complications. Radiation Therapy equipment has become more sophisticated, so that tumors can be treated with pinpoint accuracy, minimizing the toxic effects to the normal tissue surrounding tumors.

Chemotherapy has progressed not only in the number of drugs available increased to fight cancer, but in the supportive measures to minimize its toxic effects. The definition of chemotherapy has essentially been expanded to include biological and molecularly targeted drugs. We have moved from a shotgun approach in treating cancer, to multidisciplinary care, and are rapidly moving toward PERSONALIZED care - also termed INDIVIDUALIZED care. The latter has arisen from the recognition that not only does cancer represent at least one hundred different diseases based upon the tissue of origin, but that each cancer may harbor specific molecular or genetic abnormalities. These molecular abnormalities not only define how cancer behaves in a given patient, but how it may respond to various therapies. Modern day targeted drugs are like Smart Bombs, which can seek out individual cancer cells and kill them without major side effects to the rest of the body.

In many cases, we can now test a patient's cancer cells for some of these molecular markers, and provide a specific drug to more selectively kill these cells. We still use chemotherapy to fight most cancers, but more frequently targeted therapies are added to chemotherapy, and oftentimes, targeted drugs are effective by themselves. The most significant advances in targeted cancer therapy over the past decade include Rituxan for non-Hodgkins Lymphoma, Gleevec for chronic myelogenous leukemia, Herceptin for breast cancers, Erbitux for colon cancer, Avastin for colon and lung cancer, Sutent for kidney cancer and Tarceva for lung cancer, to name just a few.

A week does not go by without hearing about the next great drug, in a long line of new cancer treatments being considered by the FDA for approval. I expect the exponential growth of new therapies to continue, and that, before I retire from the practice of oncology, the types of treatment we have used to treat cancer in the past will be considered primitive and barbaric. There is no field of medicine that has progressed like oncology over the past several decades. It has been an exciting time to be an oncologist.

Many of us had the opportunity last month to watch 250 pound NFL players wear pink gloves, pink sneakers or carry around pink scarves. That was because October was Breast Cancer Awareness Month, and they were supporting this important cause. It is now November, and time to bring attention to issues related to lung cancer. I think it is most appropriate to start by reminding people that lung cancer is one of the most preventable cancers. Close to 90% of lung cancers are caused directly by smoking tobacco. Our children and current smokers need to realize that lung cancer is also one of the most deadly cancers. There are close to 200,000 new cases in the U.S. each year and approximately 160,000 deaths each year. These grim statistics should serve as enough motivation to never start smoking, and to quit if you do smoke.

The risk of developing lung cancer improves with increasing years of cessation but always remains elevated. There are now plenty of resources available to help individuals quit. You could ask your doctor, call the toll free hotline (1.800.QUITNOW) or visit www.smokefree.gov. If you need more motivation to stop, just remember that secondhand smoke is harmful, too. Our young children are affected by secondhand smoke, which can lead to lung cancer and heart disease down the road, so please adopt a smoke-free policy at home and protect our vulnerable kids. Another important but much less frequent contributor to lung cancer is radon, a gas that might be present in our homes.

Although prevention is the most effective way to combat this disease, early detection is another approach that will help individuals at high risk. A test that can accomplish this is called a screening test (something similar to mammograms used to detect breast cancer). If lung cancer is detected at an early stage, the chance of surviving increases significantly. We've been searching for the right screening test for decades, and it was just earlier this month that the National Cancer Institute announced for the first time that spiral CT scans can save lives in high-risk individuals. An annual CT scan decreased the risk of death by 20% compared to those individuals who had a chest x-ray. Of course, there are some downsides to having screening spiral CT scans, which can be discussed with your doctor.

If lung cancer is detected in an individual, it is important to be evaluated by a team of doctors that are specially trained to deal with the complexities of this disease. This team of doctors generally consists of a thoracic surgeon, radiation oncologist, medical oncologist, pulmonologist, pathologist and radiologist. Treatment of lung cancer is becoming highly individualized, offering the best chance for good outcome. The most advanced technologies are now widely available. Surgeons are using video-assisted thorascopic surgery (VATS) to remove tumors, speeding up recovery time and decreasing pain associated with surgery. If surgery is not desired or is not an option, less invasive modalities such as radiofrequency ablation (RFA) and image-guided radiation therapy (IGRT) are available. New generation medical therapies (chemotherapy) are more effective and well tolerated.

All of these innovative, advanced and highly technical approaches to the management of lung cancer allow individuals to continue on with their daily lives, spend time with family, work and do the things they enjoy. To learn more about lung cancer and what is available in our community please visit http://www.midstatecancercenter.org/.

Atrial fibrillation is a common rhythm disorder of the heart and affects about 3 million Americans today. The most common manifestations of this heart rhythm abnormality are palpitations; however, many patients may suffer other symptoms related to this chaotic and uncomfortable rhythm disorder. These include dizzy spells or passing out, sudden onset of shortness of breath, intolerance for activity, chest discomfort, trouble breathing, and often the inability to rest or sleep because of uncomfortable palpitations and irregular heartbeat.

Some patients begin to experience symptoms at a young age. Most of these are annoying, but benign and are simply related to "extra heartbeats." Patients may experience more severe symptoms (dizziness and shortness of breath). When these occur at a very young age, they may be due to abnormal circuits within the heart. Importantly, if these rhythm disturbances are not addressed at an early age they may lead to more permanent arrhythmias, like atrial fibrillation.

The good news today is that there are many treatment options for patients with symptomatic atrial fibrillation. The most important consideration is adequate thinning of the blood, called anticoagulation, because atrial fibrillation can increase the risk of stroke for many patients. In the "at risk" population, long-term anticoagulation is key to reducing the risk for future stroke.

Treatment of symptoms may be accomplished simply by control of the heart rate with medications in some patients. The use of other types of drugs to change the heart rhythm back to normal (and help keep it normal) can also be quite effective for some patients. For those who cannot tolerate medications- or where ineffective- a catheter-based operation to isolate the areas of the chaotic circulating electrical wavelets within the heart, thereby reducing or eliminating episodes of symptomatic atrial fibrillation, can be performed. This procedure is called Catheter Ablation for Atrial Fibrillation.

Research in many centers across the world has shown that catheter ablation is optimal for many patients. The best initial choice for treatment of symptomatic atrial fibrillation, however, is still unclear. The CABANA study is a National Institutes of Health-sponsored international study where patients who could be treated with either drugs or ablation will be randomized to one treatment arm and followed very closely. Hartford Hospital is one of only 2 CABANA centers in all of New England. Dr. Christopher Clyne is the principal investigator for the study and is a staff member at MidState Medical Center.

Do you ever feel that you are not fully alert or sharp enough when you are driving? Did you ever go somewhere in your car and don't remember how you got there because you were daydreaming? Did you ever nod off for an instant or had a "near miss" with another vehicle while driving? Or worse yet, were you ever involved in a motor vehicle accident and think you may have fallen asleep at the wheel just before the collision? If you have answered "yes" or even "maybe" to any of these questions, you are not alone.

Thousands of people drive each day who are suffering from untreated sleep disorders which can impair their ability to drive safely. Driving is a complex mental task which involves distinct cognitive, perceptual, motor, and decision-making skills. A driver needs to be able to simultaneously divide their attention to survey the peripheral as well as central visual environment, stay in the driving lane, adjust speed/position, and react quickly to sudden changes. There are a multitude of clinical studies that have come out of sleep research in the last several years which consistently show reductions in vigilance, mental and physical reflexes, responsiveness, and alertness in persons identified with certain common sleep disorders. Persons with acute or chronic sleep loss ( getting less than 6 hours sleep/day) and persons with sleep apnea (a common sleep breathing disorder affecting 10-15% of the population) are at particular high risk of motor vehicle accidents according to several large-scale clinical and governmental studies. It is estimated that 40,000 sleep-related motor vehicle accident injuries occur each year in the U.S. resulting in 1,500 deaths.

The incidence of chronic sleep deprivation and sleep apnea is even higher in commercial drivers and truckers. Sleep apnea has been noted in 30% of truck drivers in one large Pennsylvania study group. Over half of those truck drivers had severe sleep apnea which poses a real threat to anyone driving along side a big 18-wheeler. The estimated cost of motor vehicle accidents from improperly treated sleep apnea and other sleep disorders is $11 billion per year. Federal and state transportation agencies have started to take a closer look at this serious road safety problem. Truck drivers and trucking companies can definitely expect increased screening and regulatory legislation for the identification and treatment of sleep apnea and sleep deprivation over the next 1 to 2 years. Many commercial drivers, especially those with risk factors for sleep apnea (obesity, large neck size, hypertension) already are required to have thorough sleep evaluation which may include an overnight sleep study in a sleep center known as a nocturnal polysomnography test.

Fortunately, there is treatment available for impaired drivers with sleep disorders. One needs to be aware of some key warning signs. If you or anyone you know suffers from drowsiness or fatigue, unrefreshed sleep or frequent awakenings at night and is told they snore loudly or stop breathing in their sleep, then sleep apnea is likely. Sleep apnea is even more likely if a person is overweight or has hypertension associated with the above symptoms. Sleep apnea not only impacts quality of life and mental performance, but increases the risk of heart attack, stroke, and diabetes. In addition, people who keep irregular sleep schedules, such as shift workers and long-haul truck drivers are often chronically sleep deprived or develop insomnia, and have significant impairment and health problems as well. If any of these issues apply to you, then talk to your physician or call directly on a sleep center which specializes in the diagnosis, evaluation, and treatment of sleep disorders. Treatment can vary from behavioral management, medication, or CPAP therapy (a portable air pressure device worn over the nose or mouth during sleep to treat sleep apnea). The great majority of people benefit greatly from the proper treatment of sleep apnea, insomnia, and sleep deprivation. So remember, it is better to seek help and prevent a serious accident from occurring, than to hope you are lucky enough to avoid an accident each time you are driving Miss "Dazey."

Most of us at some point in our lives have experienced lightheadedness, vertigo and/or dysequilibrium. These symptoms may mean different things to each of us.

Vertigo by definition means that you or the room is spinning. This should not be confused with symptoms of lightheadedness or fainting.

Dizziness is a broad term that is not specific and can encompass all of the above definitions.

It is important to explain to your doctor what specifically you are feeling as this gives important clues as to what is causing your symptoms Dysequilibrium can be related to central conditions (brain) or peripheral conditions (the balance center). Your doctor has to rule out other causes such as side effects of medicine, heart related problems, metabolic issues (such as thyroid disorders) and neurologic conditions. The category of peripheral disequilibrium is where the Otolaryngologist or Ear, Nose and Throat doctor can help you diagnose your condition.

BENIGN PAROXYSMAL VERTIGO - This is a disorder of balance center characterized by a sudden spinning sensation when one looks up or down and especially when ones rolls over to one side or the other. It can last 15-20 seconds but seems like an eternity. This can usually be treated with a simple head positioning maneuver in the office.

VIRAL LABYRINTHITIS - This condition is caused usually by a virus that affects the vestibular center. There is usually a sudden onset of intense dizziness (spinning,lightheadedness), nausea and vomiting and usually the individual cannot walk and has to lie down. This intense period can last 24-36 hours and then slowly improve over several days to weeks.

MENIERES DISEASE - Menieres disease is a common condition we see as Ear, Nose and Throat doctors. It usually starts as a sudden onset of disequilibrium (spinning) with perhaps a sensation of ringing in the ears and/or temporary hearing loss just before the incident. There is usually nausea and vomiting and this can last 20 minutes to 24 hours. Medication and diet can help control this condition as it is one form of balance disorder that can occur over and over again.

ACOUSTIC NEUROMA - This is a rare condition of a benign tumor (neuroma) on the auditory nerve. There is usually a gradual loss of hearing in only one ear with possible tinnitus (ringing, buzzing, etc.) and unsteadiness. This condition can be diagnosed with the help of a hearing test and an MRI. With all forms of sudden onset of disequilibrium one has to rule out more serious conditions such as a CVA (stroke), MI (heart attack), etc. One should call your doctor for assessment and/or be assessed in the Emergency Department if you need to rule out a life threatening condition. In order to determine specifically what type of balance disorder a patient may have to complete a series of tests such as a hearing test, a vestibular assessment in the form of a VNG (balance test that is usually done at a balance center such as the one at MidState Medical Center), blood test, etc.

These are just a few of the conditions that can cause disequilibrium and if you experience these conditions a visit to your doctor and/or Ear Nose and Throat specialist may be necessary.

Dr. Willett is a board certified otolaryngologist and is an Assistant Clinical Professor, Department of Surgery, Section of Otolaryngology at Yale University. He has offices in Cheshire and Meriden (at Midstate Medical Center.)

Vitamin D, called the sunshine vitamin, is an essential nutrient which is known to fight some of the most common chronic illnesses. The name "sunshine" came from the fact that the body produces vitamin D after exposure to sunlight-ultraviolet B rays. It is believed that only 10-15 minutes of safe sun exposure on face, hands and arms 3-4 times a week during the summer time would be helpful in getting the adequate amounts of vitamin D in healthy individuals. However, prolonged exposure to the sunlight should be avoided because it is thought to be detrimental to your health, causing skin damage, as well as skin cancers to susceptible individuals. Due to sunscreen use by most people, a majority of us don't synthesize enough vitamin D naturally. As a result we need to get our vitamin D from other sources such us diet and supplements.

Role of vitamin D

Vitamin D has an important role in calcium absorption from the digestive tract, which in turn, helps in building strong bones and muscles, as well as maintaining normal levels of calcium and phosphorus in the body. A low intake of vitamin D causes osteomalacia in adults which is manifested by weak and painful bones, weak and aching muscles, as well as fatigue. Vitamin D deficiency in children leads to rickets. Recent studies suggest that vitamin D provides protection against osteoporosis, high blood pressure/ heart attack, diabetes type 1 and 2, cancers (especially colon, breast, and prostate), severe autoimmune diseases, and depression (especially seasonal affective disorder due to less sun exposure during the winter months). Daily Vitamin D supplementation also was found to decrease the risk of falls and fractures in elderly. Scientists also believe that low levels of vitamin D are linked to decreased levels of cognition.

Risk factors for vitamin D deficiency

People with medical conditions such as inflammatory bowel disease or people with inadequate diet or sun exposure can develop vitamin D deficiency. Individuals at risk of developing vitamin D deficiency are: people older than 65 (it seems that the older we get the harder it is for the body to synthesize vitamin D in the skin under the direct sunlight exposure), those who are obese, those leading a sedentary life due to insufficient sun exposure, dark skin individuals (the skin pigment blocks synthesis of vitamin D), as well as people taking medications such as anticonvulsants and steroids.

Sources of vitamin D

There are 2 forms of vitamin D: vitamin D2 and vitamin D3. D2 is known to be synthesized in plants and D3 is synthesized in humans in the skin under sun exposure ultraviolet B rays. Vitamin D is synthesized in the skin at the impact of the sunlight, found in foods, over the counter supplements and, if necessary, prescription supplements. When it comes to dietary sources of vitamin D we have foods that naturally contain vitamin D (unfortified): cod liver oil, egg yolk, salmon, mackerel, sardines, herring, tuna and then we have foods that have been enriched with vitamin D (fortified): cereal, milk, orange juice. Fresh salmon and herring have the highest amount of vitamin D per serving. Healthy people can maintain adequate amounts of vitamin D in their body by eating a diet rich in vitamin D and by having sufficient sun exposure.

Daily recommended intake of vitamin D

The amount of vitamin D you need depends on your weight, your genetic make up, your skin color and whether you have chronic medical conditions. You should always refer to the nutrition labels of the food products for vitamin D content in one serving. At the end of the day the vitamin D consumed should add up to 100%. To better illustrate this let's take milk as an example: 240 ml (1 cup) of 2% milk contains 25% of the daily recommended intake of vitamin D. For those of us whose diet does not meet the daily requirement of vitamin D we can compensate by taking a vitamin D supplement. Adults younger than 50 years need at least 400 International Units of vitamin D, those between 50-70 years old need 600 International Units and people over 70 need around 800 International Units. Children and adults with no sun exposure need 800-1000 International Units.

There is no such thing as too much naturally occurring or dietary intake of vitamin D. The body has its own mechanism of ridding itself of any excess vitamin D through the kidneys. That is not the case with supplements, however. Supplement excess can lead to nausea, vomiting, and kidney stones. As a result, patients suffering from medical conditions such as kidney stones or kidney disease, are advised against any vitamin D supplements.

If you think that you might have vitamin D deficiency or you have a medical condition that requires vitamin D supplementation talk to your doctor. He or she might run a test to find out if the level of vitamin D is low. Your medical care provider might ask you questions about your diet and sun exposure and might recommend vitamin D supplements which are available over the counter or by prescription.

So you see your doctor, and he says you have a fatty liver. What does that mean?

As the name implies, it means you have increased fat deposits in your liver cells. This is quickly becoming the most common cause of liver disease in the United States, especially in light of the obesity epidemic we are facing.

What are the symptoms if I have a fatty liver? Most patients are symptomatic at the time of the diagnosis, which is usually an incidental finding based on the results of x-rays or routine blood tests. Typically, patients complain of vague upper abdominal pain, mostly on the right-hand side, with bloating and increased nausea.

Fatty liver disease is not always serious, but it can be if the fat in your liver causes inflammation or scarring of your liver tissues. This condition is called non-alcoholic steatohepatitis, or NASH.
The most common cause of fat build-up in the liver is from insulin resistance. Insulin is the primary hormone that helps us burn excess calories and prevents fat accumulation. Insulin resistance is most common in individuals with diabetes, or those people who are obese or have increased lipids.
When evaluating patients for fatty liver disease, the doctor must always rule out of the influence of alcohol consumption as a contributing factor to a fatty liver. Therefore, individuals who drink more frequently should stop consuming alcohol for a few weeks to determine if the fatty liver is a result of alcohol use or not.

Fatty liver disease is usually diagnosed based on elevated liver function tests or an abnormal looking liver seen on an abdominal ultrasound or CT scan. Sometimes a liver biopsy may be needed to confirm the diagnosis and determine the degree of injury to the liver.

The good news is that a fatty liver can be treated. The most effective means is correcting the underlying causes: losing weight if necessary, controlling your diabetes better, and monitoring your lipids to make sure that they are not too high.

Research has shown that certain vitamins, antioxidants and insulin sensitizing drugs can also be helpful. Again, for the majority of patients, getting to an ideal body weight is the most effective way of treating the disease.

Dr. Wazaz is affiliated with MidState Medical Center and practices with Gastroenterology Specialists.

Dr. Andrew Metzger

Robotic-assisted surgery is the next step in the evolution of hysterectomy

Robotic-assisted surgery is the next step in the evolution of hysterectomy

Dr. Andrew Metzger, OB-GYN

Gynecologists have long been at the forefront in the advancement of surgical techniques, pioneering laparoscopic surgery and minimally invasive procedures. Hysterectomies originally were performed through a large vertical incision on the abdomen and later through a smaller lateral incision low on the abdominal wall. Further advances resulted in vaginal approaches to hysterectomy, and then laparoscopic assistance to vaginal surgery, and ultimately total laparoscopic hysterectomies. Now hysterectomies may be done through tiny incisions only millimeters wide, with the assistance of the da Vinci robot.

The da Vinci Surgical System allows surgeons to perform procedures with robotic-assistance by taking advantage of modern technology. Control of the instruments inside the patient is done by the surgeon at a console separate from the patient. Because the instruments are smaller and finer than the human hand, they can be introduced into the patient through very small incisions. Additionally, these instruments are not restricted to the motions of the human hand, and can rotate 720 degrees, therefore allowing access to aspects of the anatomy otherwise out of reach to traditional laparoscopy. Finally, modern optics and digital resolution give the surgeon clear, magnified, three-dimensional views of the anatomy far superior to that of the naked eye.

Advances in surgical therapy can usually be distilled to a pair of simple concepts: less risk to the patient and faster recovery. Robotic-assisted surgery brings both of these concepts to the patient. A robotic-assisted hysterectomy is done through minute incisions with instruments precisely controlled by the surgeon, so the patient experiences far less pain, lower risks of infection, less blood loss and quicker recovery. Where a traditional abdominal hysterectomy resulted in recovery times of six weeks or more marked by pain, blood loss and the risk of infection, robotic-assisted hysterectomy allows the patient to be able to return to normal activities often in two weeks or less, with dramatically fewer complications.

Perhaps the biggest advantage of robotic-assisted hysterectomy is that cases deemed too large to be done vaginally can now be done through tiny incisions. Rather than resorting to a 6-12 inch incision of an abdominal hysterectomy, a robotically trained gynecologic surgeon can now perform the same procedure without the large incision. Although every patient and case is unique, the abdominal approach to hysterectomy is rapidly becoming, and should be, a rare event.

Less risk, less pain, a shorter hospital stay and faster recovery: robotic-assisted surgery is the next step in the evolution of minimally invasive surgery. To quote one happy patient, "This isn't your grandma's hysterectomy."

Written by MidState's Andrew Metzger, MD, who practices in Meriden, Wallingford and Cheshire.

The line of volunteers for lung surgery would not wrap around the building ... even if it included front row seats for UCONN basketball. No one really wants his chest "cracked open" - even if it is potentially life saving. Large rib spreaders and large wounds sound scary. Every baseball fan knows Johnny Bench was never the same after his thoracotomy - the term used to describe the standard incision used by thoracic surgeons to enter the chest. It is usually about 8 inches long, curving around the bottom of the shoulder blade. The surgeon then divides 2 large muscles to reach the rib cage. The ribs are not "cracked". Rather, an incision is made between the ribs to enter the pleural space - the space inside the rib cage containing the lung. The ribs are spread apart for most of the procedure, causing pain that requires an epidural catheter, narcotics, and a prescription for pain pills for 2-4 weeks.

Sometimes, these incisions are absolutely necessary to get the job done. Some tumors are too big or too close to large vessels. Thoracotomies save thousands of lives every year in the United States. But a relatively new technique is becoming more popular with thoracic surgeons. Thoracoscopic surgery - or minimally invasive thoracic surgery - is now used routinely by some surgeons to perform a lobectomy. A lobectomy, in which one lobe of the lung is moved, is the gold standard treatment for lung cancer. In 2003, less than 5 percent of lobectomies were performed using minimally invasive techniques. In 2007, about 20% were performed this way. Experts agree that the number will continue to rise. Thoracic surgery training programs are producing graduates that are well trained in the new technique. Surgical journals are revealing the benefits of the thoracoscopic lobectomy.

Thoracoscopic lobectomy is the same procedure on the inside. On the outside, there is a 2 ½ inch incision and 1 to 2 one inch incisions. The ribs are not spread. A camera is used by the surgeon and assistants to view the operation on TV screens. Special instruments are designed to function through the small "port" incisions. Staplers are used to divide and seal the tissue. A sterile bag is used to remove the specimen. The same number of lymph nodes is able to be removed.

The surgical and cancer survival is no different than the traditional surgery. Some argue that survival is better for thoracoscopy because it involves less trauma to the immune system - allowing the body to kill residual cancer cells more efficiently. There is little doubt in the surgical literature that minimally invasive thoracic surgery is safe and has less complications, less pain, shorter hospital stay, and quicker return to normal life. Johnny Bench would be interested to know that shoulder strength is objectively better after this muscle sparing surgery. Surgeons are expanding its use, now using it for more advanced cancers. Studies have shown that advanced stage patients are more likely to tolerate their full dose of chemotherapy after thoracoscopy.

The same technology is being applied to other thoracic conditions. Some chest infections can be treated with small incisions - allowing the patient to recover after a less invasive procedure. Diagnostic surgeries can be performed without spreading the ribs. The standard of care for resecting bleb disease (which causes pneumothorax, or dropped lung) is a thoracoscopic approach. Surgery to treat recurrent fluid collections in the chest is best done minimally invasively. Surgeons are now removing the esophagus and reconstructing the patient with a stomach tube without spreading the ribs.

Thoracic surgery, even minimally invasive, is major surgery. Thoracoscopic surgery offers all the benefits of the standard surgery with less pain and a faster recovery. Some situations will call for the traditional incision. However, a high percentage of patients who need thoracic surgery can expect a minimally invasive approach to get them home faster and back to a normal life. And that is soon to become the standard of care.

September is Prostate Cancer Awareness Month. Each fall, we in the health professions, as well as cancer survivors and their families, try to raise community awareness of the dangers of prostate cancer. We stress cancer screening, early diagnosis, research, and as many non-invasive treatments as science can provide. One in six American men are diagnosed with prostate cancer. One in seven of those will die from the disease.

This month we should also become aware of how for we have come. Unfortunately, I am old enough to remember the bad old days before cancer awareness was promoted. I entered urology practice in the mid 1980's. In those days prostate cancer was a hush-hush subject not brought up in polite conversation. This attitude inhibited progress in fighting the disease on a community level. I can still remember the looks on the faces of the men who showed up for our first screening sometime in the late 80's. They looked shy and unsure. Not one of them brought their spouse.

But through the efforts of our various civilian and medical organizations, and through donations of money, testing, and supplies furnished by the American pharmaceutical industry (seldom recognized), attitudes changed. Screenings found cancers earlier. Nothing promoted screening like results, and especially in the early screenings we discovered many tumors years before they would have become apparent. Today, prostate screenings have become social events attended by men and their spouses. Often refreshments are served. PSA values are a topic of conversation. Research has resulted in new tests (especially PSA), and better treatments have been developed. Since the initiation of prostate cancer screenings, death rates from prostate cancer have fallen by a staggering 34%! Results like these give one the fortitude to push on, and there is obviously more work to be done.

So why doesn't every male get screened? In one word: fear. Fear of pain. As a male I can tell you that this is a very real and legitimate concern on the part of prospective patients. But there is nothing to fear from the screening process itself. The rectal exam (DRE) is quick, easy, and always non-painful. The PSA is a routine blood test; no problem there either. Then hopefully the process is over. However, if an individual is in the small number of people who screen positive, a prostate biopsy is needed. This used to be done with a relatively large transrectal probe, which could be uncomfortable for many. We now have a new generation of much smaller probes the size of a finger, so despite a few awkward moments, it's no big deal.

Of course, there is still room to improve. One problem which still needs to be solved is what doctors call the "non-specificity" of the PSA test, which is to say that not everyone with a high PSA has cancer; in fact, slightly less than half do. Efforts are underway to develop new tests to better identify those men who actually have the disease, and spare those who don't the discomfort and risk of biopsy. This has been a research interest of mine for many years, and finally a new scan to address the problem is up for FDA approval.

Dr. Kenneth Weisman practices with the Urology Division of the Connecticut Surgical Group, PC and can be reached at his Meriden office at MidState Medical Center by calling 203 238 1394

Varicose veins - everyone has heard of them, millions of people have them. What most do not know, however, is why we get them and that there are new minimally-invasive techniques to eradicate them.

There are two sets of veins that return blood from the legs back to the heart - the deep or femoral system, which does about 90% of the work, and the superficial, or saphenous system, which begins just above the ankle bone and courses up the inner aspect of the leg to meet the femoral vein in the groin. What keeps blood moving "northbound" from the legs to the heart is the muscle-massaging action of walking, but what keeps the blood from falling back down the vein are one-way valves. For a variety of reasons, including heredity, pregnancy, previous leg surgery or injury and obesity, these valves can stop functioning and the blood falls back down the veins. This is termed CVI (chronic venous insufficiency), and can manifest as a variety of symptoms, including leg pain, heaviness, burning, restlessness, ankle swelling and usually, but not always, visible varicose veins. If not treated, more severe consequences can arise, such as skin color changes, hemorrhage from the veins and skin breakdown (venous ulceration).

It is estimated that eighty million Americans are affected by CVI. Of these, twenty-seven million exhibit symptoms, twenty million have actual reflux in the saphenous vein, only 1.2 million seek treatment and only 150,000 are actually treated annually. The individual with varicose veins who complains of aching, heaviness, itching over the veins with or without swelling is often managed with advice to ignore the symptoms or try non-prescription support hose and leg elevation. This reflects a general misunderstanding by the medical profession as well as the general public. CVI is a medical condition for which there are several treatment options. Since the 1980's, when the care of such patients became standardized, with ultrasound for diagnosis and the emergence of less invasive treatment options, the public has been much better served. Of more concern, is that there are approximately 500,000 patients in the US with active venous ulcers, which is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. It also carries an annual estimated cost of one billion dollars in treatment and lost time at work.

There are a variety of treatments for varicose veins depending on the severity of the disease, the size of the veins and whether or not reflux is present. For mild leg heaviness, ankle swelling and small visible varicose veins, compression stockings, although not curative, work well. They come in a variety of lengths, colors, and fabrics, and most people claim significant symptomatic relief. For some with larger veins, including spider veins, these can be managed safely and easily by either lasers or injection sclerotherapy. The latter involves the injection of a dilute detergent foam directly into the veins causing them to shrink and eventually be absorbed by the body. Cosmetic lasering is highly successful in erasing unsightly leg or facial veins. For larger, more bulging veins, surgery is often recommended. Termed microphlebectomy, tiny incisions are made over each vein which are then surgically removed. This is well tolerated with minimum post-operative discomfort or downtime.

The most exciting new technology is for people with documented valvular incompetence causing reflux. Until recently, the saphenous vein was removed by "stripping" it out bluntly from the ankle to the groin. Although the gold standard for centuries, this procedure can be accompanied by post-operative swelling, bruising, pain and in more than 50% of cases, reformation of parts of the vein. Fortunately, in most cases, vein stripping has been replaced with a procedure called "venous ablation," whereby the vein is "shut down" by the heat emitted by a catheter that is inserted into the vein. The heat is either from a laser or radiofrequency energy. Both are effective although laser ablation has a somewhat higher incidence of pain and post-procedural bruising.

At MidState we are using radiofrequency ablation, which is performed on an outpatient basis. There are no incisions made, the procedure is virtually painless and patients may resume their usual activities immediately, including exercise. There is no swelling, minimal bruising and the incidence of reformation is less than .1%.

In summary, CVI is a condition that was poorly understood by the public. It has now been standardized into a well-documented clinical picture for which there are uniform diagnostic procedures and minimally invasive treatment options.

For more information or to reach Dr. Daniel Schwartz, call The Laser & Vein Treatment Center at 203 238 2691.

Nobody expects to have a heart attack. Many people who suffer heart attacks don't believe that it is happening to them. Often times, people attribute their heart attack symptoms to something else like indigestion.
Heart attacks often manifest as a dull pressure in the chest and not as severe pain.

We have all seen too many movies where a patient with a heart attack has severe pain, clutches their chest, and then falls over. Patients may not believe that their symptoms are severe enough for them to call their doctor or rush to the emergency room.

People are often afraid that if they go to the hospital that they will be embarrassed if nothing is actually wrong. For these and other reasons, many people delay seeking or never receive treatment for their heart attack. This usually leads to a greater amount of heart damage or possibly death due to an electrical instability of the heart.

There is no typical heart attack patient. Certainly people with a family history of heart disease or a personal history of cigarette smoking, diabetes, high cholesterol, and high blood pressure are the greatest risk.

Stress is ubiquitous in our society and also contributes to heart disease. Many patients who suffer heart attacks have few or none of these risk factors. All too often patients don't find out they have heart disease until after their first heart attack.

Despite the fact that heart disease remains the leading cause of death in the United States for both men and women, many patients don't believe that they are at risk. Denial is a powerful enemy in the war against heart disease.

Many patients believe that a stress test is a good way to assess the condition of their heart. While an abnormal stress test is usually indicative of a serious heart problem, a normal test by no means guarantees that the heart is healthy. A stress test is only designed to show evidence of severely blocked heart arteries.

Typically an artery must be narrowed 70% or more to "show-up" on a stress test.

Most heart attacks occur in arteries that are narrowed by less than 50%. This is because a heart attack is the result of a blood clot that forms on a cholesterol plaque after it ruptures.

Plaques that rupture are usually not the ones that severely narrow the arteries. Therefore it is possible to have a perfectly normal stress test and suffer a heart attack the next day. Stress tests predict the presence of severely block heart arteries, not the risk of a heart attack.

What can you do to predict your risk of a heart attack? A visit to your doctor can help to assess the traditional risk factors such as diabetes, cholesterol, and blood pressure.

In some cases, medical treatment for the conditions can greatly reduce the chance of a heart attack. In all cases, lifestyle changes including a better diet, regular exercise, and stress management reduce the risk of heart disease.

Newer tests exist to further assess cardiac risk. A blood test called cardiac C reactive protein (cCRP) shows evidence of heightened inflammation and predicts a higher riskof heart attack even in patients with relatively normal cholesterol levels. There is an x-ray test to look at the amount of calcium build up in the heart arteries. Any calcium in the arteries is abnormal and the higher the "calcium score" the greater the risk of a heart attack. Ultrasound images of the neck arteries can show if the lining of the artery is abnormally thickened. This also is a way to predict the risk of heart attack.

Patients must realize that we are all candidates for a heart attack. A visit to your doctor to assess your risk is the first step in the fight against heart disease.

The newer risk assessment technologies discussed here are not needed for everyone, but do provide valuable information in certain patients. The likelihood is that you will die from cardiovascular disease.

Why wouldn't you want to be proactive in reducing your risk?

Dr. Farrell is a board certified cardiologist with added qualification in interventional cardiology. He is a member of the medical staffs at MidState Medical Center and Hartford Hospital and the Director of the Cardiac Service Line at MidState. He holds teaching appointments from the University of Connecticut and Yale University.

Lymphedema is the build-up of fluid in the soft tissues of the body that occurs when the lymph system is damaged or obstructed. Lymph, the white blood cell containing fluid important in fighting infection, normally circulates around the body through a series of small channels or vessels. Lymph nodes are small filters in the lymph channel system that clear the lymph fluid of particles and act as storage units to house the infection-fighting white blood cells. Normally, the lymph fluid circulates continuously around the body as an integral part of the immune system. If something interrupts this flow, the fluid backs up and leaches into the soft tissue causing lymphedema.

Primary lymphedema is caused by the abnormal development of the lymph system, with symptoms seen as early as at birth. More commonly seen is secondary lymphedema, which results from physical blockage to the flow of the lymph fluid from infection, surgical removal of lymph nodes or tissue, damage to the lymph structures from surgery or radiation therapy, or scarring of tissue with resultant obstruction. As an example, the development of upper extremity lymphedema is an unfortunate post-operative/post-radiation risk after several different types of breast cancer treatments. Women undergoing lumpectomy with axillary (or underarm) lymph node sampling or dissection, women undergoing mastectomy with lymph node sampling or dissection, and women receiving post-operative axillary radiation therapy are all at risk for developing some degree of lymphedema of the arm located on the same side as the breast surgery; the incidence of development ranges from 7% to 47%.

The initial signs and symptoms of lymphedema may be subtle, such as the feeling of arm heaviness or rings being too tight for the fingers. As it progresses, tightness of the skin, obvious arm/hand swelling and difficulty moving joints can occur. Since lymphedema is difficult to treat once it is apparent, the ideal for lymphedema treatment is to make the diagnosis before it is noticeable. Unfortunately, traditional methods of early detection such as arm girth measurement and water displacement measurements are variable and frequently unreliable. Here at the Midstate Medical Group Surgical Specialists, we are piloting an early lymphedema diagnosis and treatment program utilizing ImpediMed's L-Dex ™ bio-impedance spectroscopy device. The device measures the volume of fluid in an "at-risk" arm (the arm on the side of the cancer surgery) by passing a low frequency current through electrodes on the patient, determining the resistance to the current, and comparing obtained values on the "at risk" arm to the other arm. Ideally, measurements would begin prior to cancer surgery on the patient to get a baseline reading, and then are compared every 3 months for the first 2 years after surgery, every 6 months from years 3 to 5 post-surgery, and once a year thereafter. While the risk of developing post-operative lymphedema is greatest within the first 2-3 years after cancer surgery, it is still considered a lifetime risk.

The greatest feature of the L-Dex is its ability to detect lymphedema before it is noticeable. A study published by the NIH in 2008 (Cancer, Vol. 112, Issue 12) clearly showed that when lymphedema is diagnosed at a sub-clinical stage, it could be successfully treated with wearing a compressive garment on the affected limb for several weeks. Following removal of the garment, patients had complete resolution of the lymphedema with no further intervention required. Progression to clinically obvious lymphedema, and thus to advanced, disfiguring stages, is prevented. Early detection and treatment of lymphedema in the post-operative breast cancer patient is a tremendous advancement in the care of our breast cancer patients.

Dr. Elizabeth Riordan is a general surgeon with the MidState Medical Group Surgical Specialists and is also Director of Breast Services at MidState Medical Center.

Dr. Benbrahim

Weight Loss Surgery Expected to Play a Bigger Role in Treating Type 2 Diabetes

Weight Loss Surgery Expected to Play a Bigger Role in Treating Type 2 Diabetes

Dr. Benbrahim, General and Bariatric Surgeon

Weight loss surgery is known to be the most effective and long lasting treatment for morbid obesity and many related conditions, but now mounting evidence suggests it may be among the most effective treatments for metabolic diseases and conditions including type 2 diabetes, hypertension, high cholesterol, and obstructive sleep apnea.

Metabolism is the process by which the body converts food to energy at the cellular level. The most common metabolic disease is type 2 diabetes, which occurs when the body does not adequately metabolize or regulate blood sugars due to lack of insulin or the body's inability to respond to the insulin that is produced. According to the American Diabetes Association (ADA), nearly 21 million people in the U.S. have type 2 diabetes and another 54 million have pre-diabetes.

Increased body fat is associated with an increased risk for metabolic diseases. According to the National Health and Nutrition Examination Survey (NHANES, 1999-2002), which was conducted by CDC's National Center for Health Statistics, more than half (51%) of those with diabetes had a body mass index (BMI) of 30 or more and about 80 percent of those with a BMI of 35 or more had one or more metabolic diseases.

Most research into metabolic and weight loss surgery has been limited to patients who are morbidly obese, meaning 100 pounds or more overweight (body mass index (BMI) of 40 or more) or 75 pounds or more overweight (BMI of 35 or more) with an obesity-related condition such as type 2 diabetes. According to a landmark study published in the Journal of the American Medical Association (JAMA) in 2004, bariatric surgery patients showed improvements in the following metabolic conditions:

Type 2 diabetes remission in 76.8% and significantly improved in 86% of patients

Hypertension eliminated in 61.7% and significantly improved in 78.5% of patients

High cholesterol reduced in more than 70% of patients

Sleep apnea was eliminated 85.7% of patients

Joint disease, asthma and infertility were also dramatically improved or resolved. The study showed that surgery patients lost between 62 and 75 percent of excess weight.

The most common procedures include gastric bypass and adjustable gastric banding. To learn more about the Weight Management Program or a free Weight Loss Surgery Information Seminar, visit www.midstateweightloss.org.

Dr. Benbrahim is a general surgeon with the MidState Medical Group Surgical Specialists and is medical director of MidState Medical Center's Weight Management Program.

Most people have heard the word "acupuncture" and it means different things to everyone. Some think about long, painful needles sticking everywhere on the body; others haven't a clue as to what it's all about and how it's used. This article will attempt to clarify the practice of acupuncture, briefly describe the theory behind it, and provide good news in how it has been proven to be effective in chronic low back pain (LBP).

Acupuncture originates from China and has been in practice in some form or another for 3000 years. Modern acupuncture is practiced much differently than before even the dawn of the 20th century. Today, acupuncture is performed only by licensed professionals with defined training. Offices that perform acupuncture appear slightly different than other healthcare environments. Practitioners (in Connecticut) can be a Licensed Acupuncturist (LAc), Registered or Advanced Practice Nurse, Chiropractor, Naturopath, Osteopath, Dentist, Podiatrist, Physical Therapist, or Medical Doctor.

Acupuncture is based on the movement of Qi (pronounced "chee") through the body. Qi roughly correlates to our concept of the energy or life-force that runs through our bodies. Qi is the force behind Blood, another concept in acupuncture. Blood, in addition to our definition of it in conventional medicine, is what moistens and nourishes all the organs and systems inside us. The Blood is "Yin" where the Qi is "Yang." Proper health is based upon the balance of our Yin and Yang based on the balance between activity and rest. Imbalance occurs with depletion or excess or Yin and/or Yang resulting in health issues. Acupuncture can help restore that balance by tonifying the Qi or Blood, relieving stagnant Qi or Blood, or dispersing internal conditions interfering with proper flow of Qi and Blood. To continue past this point in theory would take too long and besides we don't want anyone trying this at home!

Low back pain is very common in our society; it is the most common ailment causing missed workdays. Chronic LBP can be difficult to treat and often leads to a dead-end where all conventional treatment modalities are exhausted. Usually, this is the point at which people start thinking about acupuncture. This is unfortunate because acupuncture may be used alongside most acute and chronic illnesses to help support the body's healing process. According to the Annals of Internal Medicine (considered "the Bible" of Internists' journals), "acupuncture effectively treats low back pain." This is a rave review from the conventional standpoint for a non-conventional treatment. To treat LBP, usually 6-10 weekly treatments are required, then on occasion thereafter. Unfortunately, most insurance companies in Connecticut do not reimburse for acupuncture. However with copays for repeated conventional visits, prescriptions, and physical therapy, it may be just what the doctor ordered!

Jordan Goetz, M.D. is an Internist in practice at MidState Medical Group Primary Care Specialists in Southington. The practice focuses primary care with acupuncture provided on-site.

For further information please write Dr. Goetz care of this publication or call 860.621.6704.

Around 20 million Americans have chronic kidney disease (CKD) while another 20 million are at increased risk for it. CKD can occur in all age groups however there are well known and easily identifiable risk factors. Diabetes mellitus and high blood pressure account for up to two-thirds of all cases in the U.S. Diabetes mellitus causes damage to many organs in your body, including the kidneys. Uncontrolled or poorly controlled high blood pressure can lead to CKD, heart attacks and strokes. Certain population groups such as the elderly, Hispanics, Native Americans, South Asians and African Americans are at higher risk for CKD.

The kidneys perform vital functions that go beyond removing waste products and fluid from our body; they also regulate chemicals such as sodium, potassium, phosphorus and calcium. The kidneys are also responsible for removal of drugs and production of hormones that regulate blood pressure, help make red blood cells and promote strong bones. CKD involves kidney damage which impairs their ability to perform the aforementioned functions vital for our health.

It is therefore not surprising that multiple organ systems are involved when kidney function becomes abnormal. Complications such as high blood pressure, anemia (low blood count), weak bones, poor nutritional health and nerve damage are common with CKD. CKD also increases the risk of having heart and blood vessel disease.

Complications associated with CKD tend to happen slowly over a long period of time. As kidney damage gets worse, waste products accumulate to high levels leading to sickness. Most people with CKD do not have any symptoms until their kidney disease is well advanced. Vague symptoms can occur with CKD; the list includes tiredness, poor appetite, muscle cramps, trouble sleeping or concentrating, dry itchy skin, swollen feet or puffiness around the eyes in the morning. Some people may need to urinate more often, especially at night. Production of urine is an unreliable way of assessing kidney function; for example some undergoing dialysis for kidney failure can still make some urine which is of poor quality.

Simple blood and urine tests are used to diagnose CKD. Serum creatinine level is one such test which allows for estimation of the kidney function. Your doctor can therefore estimate the "percentage of kidney function" using simple blood tests. Further testing is sometimes required and may include an ultrasound or CT scan to get a picture of your kidneys and urinary tract. Your doctor may also ask you to see a kidney specialist (nephrologist) who will consult on your case and help manage your care. Nephrologists are trained to care for patients with CKD. In most situations, early detection and treatment can often slow down or halt further decline in kidney function. This largely depends on the stage of chronic kidney disease when such treatment is started; the earlier you start, the better you are likely to do. A comprehensive plan for CKD care includes addressing complications such as anemia and bone disease. In the absence of early diagnoses and intervention CKD progresses to kidney failure, this requires dialysis or a kidney transplant to maintain life.

In summary, CKD is prevalent and easily diagnosed. It can be associated with multiple complications which are mostly treatable. However, it is important to diagnose this early so further decline in kidney function can be prevented.

When you get out of bed in the morning, do you feel a sharp pain in your heel? If this is happening, you are NOT alone. Millions of American adults suffer from the condition known as "Plantar Fasciitis" or heel pain.

Heel pain or plantar fasciitis normally is worse first getting out of bed or from a sitting position. It usually lessens as you begin walking. The pain may return after being on your feet for extended periods of time.

Plantar fasciitis is due to the inflammation of the plantar fascia - a thin layer of tough tissue supporting the arch of the foot from the heel bone to the ball of the foot. Repeated small tears of the fascia cause pain. The cause of plantar fasciitis can usually be traced to faulty structure of the foot such as overly high or flat arches that put stress on the fascia, wearing non-supportive shoes, and hard, flat surfaces. Tightness of the foot and calf, improper athletic training, shoes that do not fit, and overuse (running too fast, too far, too soon) may hurt the fascia.

What can be done?

MidState Medical Center-affiliated podiatrist, Tina Boucher, MD, says, "80-90% of heel pain normally can be resolved in less than 6 months. Treatment consists of controlling the inflammation with many different treatment options." It has been proven that a heel spur, if present, does not cause the pain encountered, but rather it is the inflammation around the spur that makes this condition painful. First line strategies that can be done at home consist of stretching the foot, calf muscles, and Achilles tendon, icing the arch and heel a few times a day, and wearing supportive shoes. If these at-home treatments do not provide relief after a few weeks, it is best to come to the office for a complete evaluation and treatment plan. It is much easier to treat this condition earlier on during the more acute phase than months down the line.

With summer approaching, do you wear flip-flops all summer long and often feel arch pain or tired sore feet later on?

With summer just around the corner, Dr. Boucher further explains that she has noticed many people who wear non-supportive flip-flop shoes or sandals throughout the summer months who often present with this painful condition in August/September. For those who need to wear flip-flop sandals, there are some flip-flops available with an arch support built in and with room for an additional arch support if necessary.

As a man ages, his prostate tends to grow. Since the prostate is wrapped around the urethra (the tube that carries the urine out), any growth can cause bothersome voiding symptoms. These symptoms often include frequent urination, especially at night, a slow stream that is difficult to start, dribbling and a feeling that the bladder is never empty. These can all be quite bothersome to a man's lifestyle.

The traditional treatment given was a surgery called a "TURP (Transurethral Resection of the Prostate)," or more commonly known as a roto-rooter. This surgery involved a stay in the hospital of usually 2-3 days with the need for a catheter draining the bladder. It is effective therapy, but there are currently less invasive approaches available.

Most patients have also been treated with medication at some point. This too can be effective at lessening the symptoms related to an enlarged prostate. These medications come with side effects such as dizziness, changes in blood pressure and sexual dysfunction, not to mention the hassle of taking a daily medication for the rest of your life and the burden of cost.

One newer procedure that is available is the Prostiva radiofrequency therapy. This procedure is done in the physician's office. With local anesthesia, two probes are passed into the prostate tissue. The radiofrequency delivers high temperatures to the prostate resulting in destruction of tissue. It takes approximately 20 minutes to do the procedure. Patients generally go home with a catheter in place for a couple of days. Recovery is 2-3 weeks, and the main side effects usually are urinary frequency and bleeding

Another effective procedure available is Photoselective Vaporization of the Prostate utilizing the Greenlight Laser. This is rapidly becoming the standard of care worldwide. It has been available for the last 5 years and has been performed over 140,000 times. It is done in the operating room as an outpatient procedure. Through a telescope, laser energy is delivered to the prostate, causing an immediate vaporization of the prostate tissue. This allows for the channel that was being squeezed by the growing prostate to open. There is a rapid improvement in the speed of the urine flow. Most of the time patients go home after the procedure with no catheter and no need for pain medications. There is less risk of sexual side effects with this procedure than with medications or the TURP.

Additionally, there is excellent durability in terms of relief of symptoms. (Of note, the first Greenlight was just performed at MidState.)Fortunately, the treatment options for enlarged prostate continue to improve as more minimally invasive procedures can be done that maximize lifestyle while minimizing the risk of side effects.